Knickerbocker, Ruth )47
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Ruth Knickerbocker j Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 1, 2011 89 War or Dates No
Place of Death Hospital, Institution or
Z City, Town or Village Granville Street Address Orchard Nursing & Rehab Center
titt
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
ALI Circumstances Investigation
Medical Certifier ame Title
,4 ()
Address
Pa.0 1/ •
Death Certificate Filed District Number Register Number
City, Town or Village T/Of Granville S7S7, a b
❑Burial Date Cemetery or Crematory
❑Entombment September 2, 2011 Pine View Crematorium
Address
0 Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
Hold
co
O Date ! Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443 _
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tii
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 0`l loa 1ao II Registrar of Vital Statistics /tcc WARP
(sr nature)
District Number NY-054321 Place Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition y h i 1, Place of Disposition R%1Q;Li
2 (a re
CO
(section) (lot numb (grave number)
pName of Sexton or Pe son in Charge Premises /LA 74 40,41-
'Z (please print)
Signature Title (11 E k R t�tt,
(over)
DOH-1555(02/2004)